Action Oriented Monitoring Report Deoghar District Jharkhand

Action oriented monitoring report

Deoghar District Jharkhand

Mr. Pradeep Tandan Consultant NRHM I Ministry of Health and Family Welfare, Nirman Bhavan New Delhi. [email protected]

Executive summery

Approach and methodology:

Background

Performance in last one year (2009-10)

Qualitative report of Deoghar district

Facility wise report

District hospital Deoghar – Sadar

Recommendation

Jashidih CHC

Sarwan CHC

Sarath CHC

Palajori CHC

APHC Kusmil –

APHC Burhai –

HSC Rohini-

HSC Bedia :-

HSC Bagdaha:-

HSC, Babhandiha:-

HSC, Dahua:-

HSC, Gopibandh:-

Annexure1 : District level monitoring format

Annexure 2: Facility assessment format

2.1 Sadar Hospital

2.2 Sarwan Hospital

2.3 Sarath Hospital

2.4 Palajori Hospital

2.5 Jasidih Hospital

Annexure 3: District Profile

Annexure 4 : Human resources in Deoghar District.

Executive summery

In April 2005, Government of India launched National Rural Health Mission to make improvements in the health system and health status of the people in the rural areas of the country. The major goals of NRHM are to reduce the Maternal Mortality Ratio (MMR) to 100 per 100000 live births from 407, Infant Mortality Ratio (IMR) 30 from 60 and Total Fertility Rate (TFR) 2.1 from 3.0 during the 7 years period of NRHM. In 2010, although NRHM completed 5 years we still lag behind in achieving the targets to accomplish the goals set for year 2012. To achieve them in next two years (by 2012) Ministry of Health and Family Welfare identified 235 district as high focus district among total 642 district of the country and decided to do action oriented monitoring. In the 1st phase of action oriented monitoring 122 high focus districts have been selected. Deoghar is one of the high focused districts (identified in 1st phase of action oriented monitoring). The visit to Deoghar district (26th of April to 1st May) revealed certain important insights, which are presented in the following document.

Brief Review: Deoghar district is located in north eastern part of Jharkhand state, with total population of 1165390. The health system is existent in the form of 8 CHCs, 5 APHC and 181 HSCs and catering health services to the rural and urban populace. The district’s visit depict that, there is a need to address following issues.

Major issues: ° There is huge deficit of health ° The participation of village health facilities (PHCs/APHCs) as comitties is poor, which is compared to the requirements reflected by the scanty utilization under IPHS. of funds, deficient understanding of the fund utilization procedures. ° Lack of human resources at important positions such as district ° There are no sick newborn units program coordinator. (DPM post (SNCU) in the district. There are vacant since 90 days) no newborn child care equipments in the any facility of district. ° Improper facilities for conducting ANMs are not trained in newborn deliveries need to be addressed. care skills.

° No waste disposal mechanism ° Poor maintenance and repairs of existent in the health facility ( the equipments in health facilities except Sadar hospital) (PHC, CHC) and laboratory is noted. ° Water scarcity is major problem for Jashidih CHC and other HSCs. ° Safety issue for new constructed CHC and PHC building.

° District hospital: issues with burn care unit and labour room.

Situation: New buildings were constructed for the four CHCs and one APHC. Other two buildings are in construction phase and are likely to be available in coming six months. the selection procedure for posts of the block program managers is completed with their probable date of joining to be finalised.

It was noticed during the interaction that the health officials in Deoghar district are enthusiastic for improvement of health services delivery. Their motivation can be maintained with periodic encouragement from the state officials

Approach and methodology:

The visit to Deoghar District of Jharkhand state was made from April 24th to May 1st of 2010.The observation method with inspection approach was used in this visit for action oriented monitoring of the high focus district Deoghar. State programme manager was not in the state during visit, so directly went to district. A meeting was conducted with civil surgeon and district programme unit. District programme manager was not in district from last few months. The format was shared and discussed in the meeting and the objective of the visit was communicated with district Programme unit. In meeting, planning for the field visit was done with district programme unit following health institutions were covered in the field visits:

Date Place Activity 26.04.2010 District place and Sadar Meeting with C.S. and DPU hospital 27.04.2010 Jashidih (CHC) Meeting with MOs and SN Kusmil (APHC) ANM Burhai (APHC) Rohini (HSC) 28.04.2010 Palajori (CHC) Meeting With ANM, MPW , Bedia (HSC ) MO, ASHA/SAHIYYA and Bagdaha (HSC) VHSCs Babhandiha ( HSC) 29.04.2010 Sarwan (CHC) Meeting With ANM, MPW , Dahua (HSC) MO, ASHA/SAHIYYA Sarath (CHC) Gopibandh (HSC)

Assessment of the health facility was done based on the monitoring format by inspecting every part of the health institution. The format was shared with the Medical Officers in detail to communicate the expected standards and scoring pattern. With the medical officers, ANM, SAHIYYA and RKS and VHSC (GKS) members discuss the different issue related to health services at the visited facilities.

Background Deoghar district was formed in 1983. Earlier it was a sub-division of Santhal Pargana district. It is located in north-eastern Jharkhand and is surrounded by Dumka [North-East], Rajmahal and Bhagalpur; [North-West Munger] ; Hazaribag [in the West] and Giridih districts [and in the South]. The district head quarter is located in Deoghar town. Man and Munda were among the primitives of this area.

Table 1: Major health indicators of Deoghar Indicator Deoghar Jharkhand

CBR 28.4 26.8

CDR - 7.5

IMR 67 50

MMR 371 371

TFR 2.71 2.71

(Source: District health action plan, Deoghar 2009)

Table 2: Major indicators in district Deoghar

Indicators Deoghar District Jharkhand State Population (in lakhs) 11.65 265.4 Average annual exponential growth rate 2.44 2.31 Population Density (per sq.kms.) 468 338 Sex ratio 914 941 Percent urban 13.8 22.24 % Population person 0 to 6 years: 18.9

Person 220003 4556827

Male 111492 2522036

Female 108511 2434751

Percentage of literate population 50.6 43.71

Male 66.9 55.07

Female 32.3 31.62

Source: Census,2001

The population density, annual exponential growth rate, of the district is higher as compared to the state. However the district has lower sex ratio, as compared to the state. The district is reported to have literacy rate of 50.6 percent (66.9 % males & 32.3 % females). About 12.8 percent of the population of the district lives in urban areas in contrast to 22.24 percent in the state.

Table 3Total number of block Panchayats and Villages

Sl. No. Name of Block Total No. of Gram Total No. of Panchayats Villages

1 Deoghar 29 348

2 Mohanpur 29 381

3 Sarwan 26 458

4 Devipur 17 214

5 Madhupur 24 256

6 Karoan 24 206

7 Sarathh 27 343

8 Palajori 17 265

Total 193 2471

The block wise distribution of population in the Deoghar district. As clear from the table, the block Deoghar is the most populous among all the blocks. Out of these 8 blocks, the blocks viz. Deoghar, Mohanpur, Sarwan, Devipur, Madhupur, Karoan, Sarath and Palajori have been designated as non tribal blocks.

Table 4: Scheduled cast and scheduled tribe population in Deoghar district

Population Percentage of Area (census 2001) Population (In Sq. No Block name kms.) Total SC ST SC ST

31778.7 1 Deoghar 256063 36411 10316 14.2 4.0 8

36186.8 2 Mohanpur 143479 20869 14854 14.5 10.4 4

3 Sarwan 308.7 128938 16841 10814 13.1 8.4

4 Devipur 400.0 84658 11005 9347 13.0 11.0

30836.9 5 Madhupur 167773 22023 22842 13.1 13.6 8

25841.1 6 Karoan 119497 10405 18811 8.7 15.7 0

8025935 7 Sarathh 136950 19772 19022 14.4 13.9 7

8 Palajori 3029.83 128032 9537 36711 7.4 28.7

Total 2479 1165390 146863 142717 12.60 12.24

Performance in last one year (2009-10)

The performance of this district is described from the progress report of April 2009 – March 2010. It can be easily noted that the districts have performed well in some areas (fund utilization of untied fund of ANM’s, family planning) however; it has underperformed in some areas (immunization, Antenatal care).

1. The immunization rate in the district was noted to be 71 % and it ranked 19th among all 24 district.

2. In maternal health, only 67% ANC registration was achieved during 2009-2010 period and it was 17th rank. Only 38% achievement in all 3 ANC coverage (19th rank) in Deoghar district .29% achievement in institutional delivery (13th rank) in the period of 2009-2010 by Deoghar district.

3. In family planning (Tubectomy) Deoghar district was 2nd in Jharkhand with achievement of 114%. 27% achievement in IUD insertion and rank was 17th in state.

4. Deoghar district was 2nd in Jharkhand in achievement of cataract operation with 161% of achievement. 65% of RCH fund of NRHM was utilized by district. 86% of untied fund of HSC was utilized in Deoghar district. Only 15% untied fund of VHC was utilized in district during period of 2009-2010. 69% fund of hospital management society was utilized by Deoghar district. (Based on the progress report of State programme unit)

Qualitative report of Deoghar district As per existing norms one Health Sub centre [HSC] is established for every 5000 population ( tribal areas=3000), one primary health centre (PHC) for every 30,000 population( tribal area 20,000) one CHC for every 1, 20,000 population (tribal areas =80,000).

In Deoghar district, 181 Health Sub centers, 5 Additional Primary Health Centers, 8 Community health centre, 1 FRUs and One District Hospital are functioning.

Blocks CHCs PHCs HSCs

Populatio Existin Need E x i stin Need E x i stin Need n g (In No.) g ( In No.) g ( In No.) (In (In (In covered No.) No.) No.)

Deoghar 256063 1 1 2 8 17 31

Mohanpur 143479 1 1 0 5 31 31

Sarwan 128938 1 1 1 5 29 29

Devipur 84658 1 1 0 5 11 21

Madhupur 167773 1 1 1 7 13 34

Karoan 119497 1 1 1 5 21 24

Sarathh 136950 1 1 0 5 30 30

Palajori 128032 1 1 0 5 29 29

Total 1165390 8 8 5 45 181 229

Above table reveals that as per the population norms still 40 more PHCs required to be setup. As in case of HSCs, total HSCs are required 229. Deoghar district has 181 existing HSCs. Therefore, Deoghar district needs 48 more HSCs.

HSCs :-

Health Sub Centres are mostly maintained by one ANM’s in the district. ANM’s are providing OPD’s in the morning and regular community visit in days. They dispense family planning, ANC commodities and assist in routine immunization and Polio immunization programme. In Deoghar district ANM are providing facility of normal delivery in sub centre. The most importunate issue was that in all sub centres, labour board was rusted and bare board was using for delivery.

Table 5: Gap between the existent and needed facility

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APHCs –

In district there are 5 APHCs. During visit one of the APHCs was shifting to new building and new building is prepared for another APHC Kusmil. 3 APHCs are in rent building. In the Deoghar district APHC only provides OPD Services. There are no equipments and facilities in APHC’s for conducting deliveries. Thus, APHC is even though equivalent to PHC’s do not conduct institutional deliveries. 45 PHCs are more required in district according to IPHS norms but only 5 PHCs are in the district there is huge gap in this facility.

BPHCs –

There are 8 CHCs/ BPHCs in the Deoghar district. Newly constructed building is ready for 6 CHCs. CHCs are providing 24x 7 services. Presently none of the CHCs is providing specialist services. Cold storage for vaccines are present in CHCs and they are properly maintaining the cold chain. Some CHCs MS are posted (like CHC Palajori ) but due to lack of infrastructure they are not able to provide specialist services. New buildings are good and after shifting, we can hope for good services.

Sadar Hospital/ District hospital :-

There is one Sadar and one referral hospital in the district. The Sadar hospital is functioning but there is quite a lot of scope and need for improvement. Ultrasound machine is present in Sadar hospital but lack of radiologist or trained person presently machine is useless. Thus there is need to ensure that radiologist are employed or provide training to someone at the earliest. Burn ward is open in district hospital it looks like more prone to increase the complication rather than improve the condition of the patient.

Maternal and Child Health:-

In last one-year, (2009-10) total ANC registration was 71% against the targeted value and Deoghar district was 16th rank in Jharkhand district. Achievement for all 3 ANC check up was only 38% against targeted value and 19th in Jharkhand. Institutional delivery in Deoghar district was only 29 % and 13th among 24 district of Jharkhand. Achievement of full immunization was 71% in Deoghar district during the period of 2009-10 and it was 19th rank in Jharkhand district.

In the interaction with ANM, Sahiyya it was revealed that focus of anti natal care (ANC) was restricted to the distribution of iron and folic acid tablets and T.T injections; however they were alarmingly unaware of the critical parts such as measurement of blood pressure and its importance from the maternal health point of view. Secondly substantial number of health workers were not able to provide comprehensive information on nutrition related issues in the pregnant women. Going further it is noticed that, although women receive iron supplementation and T.T. injection they hardly receive complete ANC check-up

by doctors. ( reflected by last year’s performance where 1st ANC registration was 71% and it was drop down in only 38% in all 3 ANC check up)

To our notice it was seen that, those health functionaries who are trained in ANC cannot sustain the application of knowledge due to lack of instruments at the PHC level. ( facilities for Haemoglobin testing and B.P. of pregnant women is not available at facilities below the CHC level).

In the case of intra natal care it was found that, due to JSY the numbers of women undergoing institutional deliveries are on the rise. All the facilities are using the bare labour board, most of them are rusted, and lack of quality in institutional delivery may be deterrent to safe delivery. Proper labour board with mackintosh and hygienic condition is required in all the institution in the district for safe institutional delivery.

During interaction with Shiyya and ANM it was found that they are doing PNC visits in the community. 24 houses stay was maintaining in the Sadar hoapital and CHCs but lacking in HSCs.

Routine immunization was conducting on Thursday and Saturday in district. Shiyyas are also helping in routine immunization in district. There is no sick new born unites in the district. There is no “child care skill” trained ANM in the district. There are no newborn child care equipments in the any facility of district.

Home delivery

Home delivery without SBA was 10.83% in district in the period of 2009-10 and home delivery with SBA was 7.46%. There is no tracking system in district for home delivery and unreported delivery. Sahiyya is appointed according to habitation; it will be easy to track the pregnant woman and also home delivery through Sahiyya . However, there is needed to make proper tracking system for home delivery.

Janani Suraksha Yojana

JSY is working well in the district. There is no backlog before March all the payments are clear. In Deoghar district, they are providing 500 INR for home deliveries but this is only for BPL families. Under JSY there is package of 2000 in district in which 1400 for pregnant woman, 150 for Sahiyya , 200 again for Sahiyya after completion of BCG vaccine and 250 for travelling of pregnant woman.

Interactions with Sahiyya ,ANM and beneficiaries it was revealed that Sahiyya spend a lot of money and energy traveling back and forth to the hospitals for securing payments. It was also found that corruption involved in JSY, Sahiyya’s are not getting there incentives properly some hospital staffs are demanded share in the incentives.

Village Health and Nutrition Day In the district total 11948 Village Health and Nutrition Days were conducted between January 09 to March 10. Sahiyya ANM and Anganwadi workers are helping to conduct the Village Health and Nutrition day. Every Thursday is fixed for the Village Health and Nutrition Day and routine immunization are conduct from same centre. ANM are providing the Immunization services, Anganwadi worker are providing the nutrition support and Sahiyya provides support to both of them.

Sahiyya/ ASHA –

2957 Sahiyya are selected in the district. Among 2957 Sahiyya 1389 were trained up to module 4, 2561 were trained up to module 3 , 2764 were trained up to module 2 and 2688 were trained in only 1st module. During visit discussion was done with total 7 Sahiyya from different village in different issues. It was revealed in discussion that they are unsatisfied with the incentives. It was found that there were lacks of motivation in some of the Sahiyya to work for community. It was found that all the drugs of drug kites of 2 Sahiyya were expiry dated. Interacted all 7 Sahiyya were trained up 4th module and it was found that they were aware about the concept of all the 4 module training.Shiyyas are providing support in routine immunization, JSY programme and other national health programme . But there is need to increase the motivation among Shiyya and strengthen in Shiyya programme in the district.

Village Health Committees:-

In Deoghar district, Village Health and Sanitation committee is known as Village Health Committees. In the period of (2009 -10) only 15% untied fund was utilized by the committees. During interaction, it was revealed that committees were aware about 1000 fund but unaware about “how to use and where to use the fund”. Total 2277 Village Health Committees are functional in the district but there is need to empower the committees for the proper functioning.

Hospital management society/ RKS: -

In Deoghar district during period of (2009-10) 69 % fund of hospital management society was utilized. In interaction, it was revealed that there is a lot of fear and confusion among the MOIC’s about the purpose of utilization. However, they are interested to utilize the fund and they strongly feel the need of some short of workshop or training to understand the utilization process and purpose .Some are using it in proper way (Palajori CHC use the fund to outsource Security guard and one group D staff).

Bio medical waste management:-

There is no bio medical waste management in the district health institutions except Sadar hospital .During visit it was found that none of the hospital were using any dust bin or colour coded buckets for biomedical waste. Needles were spread in Palajori CHC, bio medical waste were spread in Sarath CHC and same condition was in the Jashidih CHC. Needle cutters are given to every institution but none of the institutions were using it.

Human resource Issues: -

The DPM position is vacant since last 3 month and BPM in all block of district are also not appointed in the blocks, hence monitoring and supervision of the programme implementation and further organizing and planning processes at the DPMU are suffering.36%( 22/60) of medical officers are vacant in the district ( annexure 4 ). There is also an acute shortage of Paramedics in the district (Ex. 77.27% post of Formasist ,64.70 post of lab technician. 57% ophthalmic assistant ,71.42% of male health worker are vacant in the district) . There is no Radiographer in any CHCs. Only seven CHCs have 1 compounder.

There should be at least 2 compounders in each of the CHCs, at CHC level, according to the staffing norms for CHCs. Vacant post of ANM and SN in the district are also major issue.

Issue with newly constructed buildings:-

There is no platform in the laboratory rooms in the newly constructed building of the Jashidih CHC and APHC Burai. There is need of security of the newly contracted building (water pump of newly constructed Kusmil APHCs was stolen by some anti social aliment)

Facility wise report

District hospital Deoghar – Sadar

Sadar hospital Deoghar is present in the centre of the district headquarter. It is well connected and accessible to the parts of district. It is a 100-bed ISO certified hospital with 24 X 7 maternal cares. However, there are some impotent issue in the Sadar hospital.

Patient load in district hospital

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Graph shows that OPD load was increased in month of July and February, we can plan the preventive measures and alter the system according to previous history of OPD , IPD and previous emergency patient load

Facility assessment

Sadar hospital scored 82 out of 125 based on the facility assessment format.

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Sadar hospital Deoghar scored poor in bio medical west management and good in service out sourced and Janani suraksha youjana , but there are many issues in Sadar hospital some of them are

Gap statements

1) Number of specialists available at the district hospital is far less than the sanctioned posts as per IPHS norms leading to unavailability of OPD services for respective Specialities.

2) The IPD lacks the essential equipments needed for conducting required procedures as desired at district hospital.

3) Respective doctors do not visit patients in the wards regularly.

4) Number of staff nurses in the district hospital is for less than sanctioned post as per IPHS norms. 5) Emergency OT is not available to help and manage the emergency cases as required under the IPHS norms.

6) The OT lacks some essential equipment needed for conducting required procedures and surgeries as desired at district hospital.

7) Maintenance and calibration of equipments are not done regularly, which affects the accuracy of the result as well the life of the equipments.

8) A qualified radiologist is not available in the hospital.

9) Crowding and chaos at the entrance of the hospital building and the OPD counter due to lack of space

10) Basic facility like toilets drinking water, telephones etc are sufficiently not available at the OPD for public conveniences.

11) Wheel chair is not available in the OPD and emergency

12) Patient’s visitors lead to unnecessary crowding in the wads at all hours. Thus hampering the services of the wads .Security needs to be strengthened in the wards.

13) Basic patient facilities like bedside lockers, chair, drinking water etc are not available in the wards.

14) Emergency OT is not available to help and manage the emergency cases as required under the IPHS norms.

15) Number of paramedical staff in the district hospital is far less than sanctioned post as per IPHS norms, thereby affecting patient care across all service areas.

16) The X ray department does not meet the AERB guidelines

17) The X ray machine has never been calibrated

18) The Laboratory test are performed in the waiting area due to lack of spaces .

19) The sterilization of the equipment are not full proof due to the non availability of sterilization mark strips.

20) The store department in the hospital has limited space.

21) Labour room is in 1 st floor. Left and slop is not present. Stretchers are using to shift the patient before and after labour to ground floor.

22) Burn unit is open, crowd and no cooling facility in burn unit.

The interaction with incharge hospital superintendent revealed some impotent issue that

1) Security and housekeeping both needs to be strengthen

2) Proper water supply and electricity are two major problem in district hospital

3) No causality section

4) O.T. staff is anther impotent issue , number of O.T staff is far less than sanctioned post as per IPHS norms ( no O.T. assistant, and dresser)

5) Ultrasound is closed due to unavailability of proper-trained person.

Recommendation

1) There is need to shift the labour room in ground floor or make some proper and safe arrangement to shift the pregnant woman to 1 floor . 2) Due to high patient load and according to IPHS norms there is need of more doctors in the hospital. 3) There is a need to set up neonatal care unit in the district hospital. 4) Ultrasound machine is present in the district hospital, so hospital and district authority should think to send someone for training.

Jashidih CHC

Jasihdih CHC was visited on 27th April 2010. CHC Jashidih catering the population of 304466 approximate (projected population based on census 2001). It has 17 HSC. CHC Jashidih has two medical officers both are MBBS doctor .6 other medical officers of additional PHC of Jashidih providing their services to CHC. New building

is constructed and local administration is planning to shift it within a month. It is upgraded as CHC from PHC in session 2009-2010.

Facility assessment –

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CHC Jashidih scored 37 out of 125 based on the facility assessment format. Infrastructure is very poor. Service availability is also very poor. CHC scored well in JSY, recodes and reports. During visit, it was found that no IPD patient was admitted. Maintenance and calibration of equipments are not done regularly and properly. Labour wards need to improve. There was not any functional O.T. and condemned article stored in wards.

Issue in new constructed building – laboratory room has no platform and lack of proper lighting. Lack of proper water supply is another issue for the new constructed building.

Recommendations

1) According to local authority CHC Jashidih will shift in new building in next 2 month, but before it hospital and district administration with district programme unit should plan properly for Bio medical waste management, physical facility for laboratory and out sourced facilities like housekeeping and security.

Sarwan CHC

Sarwan CHC was visited on 29th April 2010. It is on the district road. CHC Sarwan cater health services to the population of 153311 approximate (projected population based on census 2001). It has 31 HSC. One medical officer is in CHC Sarwan one MBBS and other is contractual AYHUS doctor. CHC hospital administration also taking services in CHC from 2 other medical doctors of it’s additional PHC. CHC Sarwan is upgraded as CHC from PHC in session 2009-2010. New building is constructed and local administration is planning to shift it within a month.

Facility assessment

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CHC Sarwan scored 64 out of 125 based on the facility assessment format.CHC Sarwan cored poor in infrastructure

During visit it was found that there was no dressing table. Condemned articles are stored in labour room and O.T. Laboratory was well maintained but labour room and O.T need to improvement. Condition of toilet was very poor. No patient was admitted in IPD. Cold chain for vaccine was proper maintained. Conditions of cots were bad, it was rusted and mattresses were worn.

During interaction with medical officer it was revealed that they are not proper aware about utilization of untied funds. It was also found that doctors are keen to improve the hospital services.

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Above graph shows that in last year OPD Load was more in the month of July and IPD load wad high in month of February. We can plan for proper management in coming month of July in the CHC on the basis of previous OPD recodes.

Recommendations

According to local authority CHC Sarwan will shift in new building in next 2 month, but before it hospital and district administration with district programme unit should plan properly for Bio medical waste management and service delivery pattern according to the present weakness.

Sarath CHC

Sarath CHC is located by the side of district road. CHC Sarath is upgraded as CHC from PHC in 2009 -2010 session. New building is constructed and local administration is planning to shift it within a month. 2 MBBS and one gynaecologist are providing services to CHC Sarath.

Facility assessment

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Graph 6 Facility assessment Sarath CHC

CHC Sarath scored 58 out of 125 based on the facility assessment format. Infrastructure and Bio medical Waste management is very poor in the CHC .During visit it was found the cold chain maintenance for vaccine was proper. They put the name of centre and address in vaccine box for proper identification and which is a good practice. There was no dressing room and bio medical waste was spread near the dressing table .In labour table was bare and it was common practice in area to use the bare table for labour. Window glasses were broken and during interaction with medical office inchage it was found that security was a major concern specially at night .

Recommendations

According to local authority CHC Sarath will shift in new building in next 2 month, but before it hospital and district administration with district programme unit should plan properly for Bio medical waste management and service delivery pattern according to the present weakness.

Palajori CHC

Palajori CHC is located by the side of district road. CHC Palajori is upgraded as CHC from PHC in 2009 -2010 session. New building is in construction phase. 2 MBBS and one general surgeon are providing services to CHC. CHC Cater the health services to the population of 152234 approximate (projected population based on census 2001). It has 29 HSC.

Facility assessment

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CHC Palajori scored 69 out of 125 based on facility assessment format.CHC Palajori scored poor in infrastructure and services availability . Equipments, supplies and Function of Janani Suraksha Yojana was good in CHC Palajori . One aya and security guard were out sourced by the fund of hospital management society. Labour was well maintained but O.T. was not in functional condition. Bio medical waste was major issue in the hospital, needle cutter was in working condition but not used by employees, and they store the needle in ordinary carton. Deep burial pit was available but employees are not using it. During visit this issue was bring to notice of medical officer inchage and he took immediate action on this issue.

Recommendations

According to local authority CHC Palajori will shift in new building in next 2 month, but before it hospital and district administration with district programme unit should plan properly for Bio medical waste management and service delivery pattern according to the present weakness.

APHC Kusmil – APHC visited on 27th April 2010. Two medical doctors are providing services in APHS. One in MBBS and other is paediatrician. Infrastructure is huge problem in APHC. New building is constructed but APHC yet to be shifted local authority is planning to shift it within a month. During interaction it was revealed that security is a major concern in APHC (one motor pump was stolen and glasses of newly constructed building was broken by antisocial aliments). Only OPD service is providing in the centre.

APHC Burhai – APHC visited on 27th April 2010. On the day of visit APHC was shifting to new building. 2 medical officers are currently providing service in APHC among then one is MD medicine and other medical officer is general surgeon. There is lack of paramedical staff in the APHC. Only OPD service is providing in the APHC.

HSC Rohini- HSC Rohini was visited on 27th April 2010.HSC was running in newly constructed government building. During visit ANM was providing the OPD services to community. During visit normal delivery facility was not state. ANM is providing the scheduled immunization to children on Thursday and Saturday. ANM also visits the community and providing different services and conduction health education activity. Recodes was properly maintained by ANM.

HSC Bedia :-

HSC Bedia was visited on 28th April 2010. HSC was running in a kaccha house and condition was not good. During visit ANM was providing the OPD services to community for common illness. ANM provides the family planning immunization

and National health programme services. ANM also stared the adolescent health activity for girls in centre.

HSC Bagdaha:-

SHC Bagdaha was visited on 28th April 2010. ANM’s quarter was in the sub center. Open needles was not disposed and it was spread in the centre. There was no store room in the Sub Centre and some drugs with expire dates was on the table of ANM. During interaction with ANM it was revealed that AMN visits community every day from 4:30 pm to 6 pm and providing different health services.

HSC, Babhandiha:-

SHC Babhandiha was visited on 28th April 2010.During visit it was closed. With interaction to community it was found that water is a major issue in the sub centre. Villages told during interaction that ANM visits community regularly and providing different health services to the community

HSC, Dahua:-

SHC Dahua was visited on 29th April 2010. SHC was well maintained. Available Drug list was display on board. Labour room was clean but bare table was using for the delivery.

HSC, Gopibandh:-

SHC Gopibandh was visited on 29th April 2010. During visit ANM was providing OPD services. One pregnant lady was in labour room but here also bare table was using for the delivery. Condition of the building was poor. Common equipment used for labour was not maintained properly.

Recommendation for district

∑ Fill up the post of district programme manger so that ensure the processes of planning, organizing and monitoring are carried out in the district. ∑ Stop the use of bare labor board for delivery in all the health facility in district and provide the mackintosh to all the health facilities ∑ IMNCI tanning should be taken up as soon as possible. ∑ Cleanliness and hygiene in the health facilities to ensure infection control and not to harm the patients should be the objective. ∑ No waste disposal mechanism existent in the district there is needed to develop proper waste disposal mechanism in the district. ∑ All CHC are soon shifting to the new building, district health administration and programme management unit should plane properly for shifting and analysis the present weakness to overcome it. ∑ Sahhiya workers are doing well in district however there is lack of motivation among the Sahiyya in the district .District programme unit should plane for some motivational programme for them. District health administration and programme management unit ensure the Sahhiya as bridge between the community and health system not as assistant to the ANM’s. ∑ VHC’s need to be empower in district to play active part in improvement of the health of community and properly utilization of the untied fund.

Annexure1: District level monitoring format

Monitoring format for Consultants visiting High Focus Districts – Final

1. Name of consultant ------Pradeep Tandan 2. Place of visit and date ------Deoghar (24th April to 1 May )

Progress against Monitorable indicators in District (wherever applicable)

Activity / Measurable indicator Achievement Target Addition in/up to 2009-10 (Cumulative) during the in/up to 2010- year

2011

I Monitoring Progress Against Standards:

A Maternal Health Outputs

1 Institutional Deliveries 11525 Data is not Data is not available available

2 24X7 Facilities (includes PHC, CHC, SDH CHC 8 Data is not Data is not minus FRUs) available available PHC 5

FRUs 1

3 Functional First Referral Units (including 1 ( SDH) Data is not Data is not CHC, SDH, DH) available available

4 Functional Sub Centres 181 NA NA

B Child health

5 Sick New Born Units (SNCU) 0 NA NA

6 Stabilization Units in CHCs/ BPHCs NA NA NA

7 Full Immunization 100 71.46

C Population Stabilisation:

8 Male Sterilization 1200 65 NA

9 Female Sterilization 6400 7320 NA

10 No. of IUD insertions 11113 3038 NA

D Disease Control :

11 Case Detection Rate of TB among new 55% NA NA sputum positive patients

12 Treatment Success Rate among new sputum 92% NA NA positive patients initiated on DOTS

13 ABER for malaria 8.95% NA NA

14 API for malaria 0.2/1000

15 No. of Reconstructive surgeries performed 0 under NLEP

16 Annual New Case Detection Rate for 16.8% Leprosy

17 Cataract Surgeries performed 3400 5466

II Human Resource

18 Appointment of ANMs 302 302

19 Appointment of staff nurses 14 14

20 Percent of ANMs trained as Skilled Birth 240 Attendant

21 Doctors trained on EmoC

22 Doctors trained on LSAS

23 Doctors trained in NSV/ Conventional vasectomy

24 Doctors trained in Abdominal Tubectomy (Minilap)

25 Doctors trained in Laproscopic Tubectomy

26 Personnel trained in IMNCI 161 1794

III Communitisation Processes.

27 Functional VHSCs 2277 1772

28 ASHAs completed four modules of training 2957 1122

29 ASHAs with Drug kits 2957 2623

30 Percent expenditure of NRHM funds through 19% Non Governmental organizations

31 Percentage Districts having community 31%

monitoring system in place

IV Flexible Financing

32 Percent utilization of untied grants

V Improved Management:

33 Percent districts uploading timely HMIS Data Yes and confirming

34 Tracking of pregnant mothers and children Yes

35 Computerisation of HMIS Yes

36 Cold Chain Management Yes

37 Procurement System

38 Functional Mobile Medical Units 3

39 Poor performing districts sub-plan made with targets, and quarterly review shows progress

40 Difficult, Most Difficult, inaccessible area Difficult 46 thrust in provision of infrastructure and

human resources.

SERVICE GUARANTEE MONITORING PARAMETERS

• PARAMETER BASELINE PROGRESS PROGRESS IN LAST IN QUARTER QUARTER ( VISITED ( SPECIFY SPECIFY QUARTER ) QUARTER )

• Percentage of VHND conducted versus 11948 Village Health and Nutrition Days planned (Jan 09 to in the District Percentage of VHND March 10) conducted versus Village Health and Nutrition Days planned in the District

• Deliveries conducted per skilled Birth NA Attendant per month in the block. Facility wise performance may be monitored at the district level. Increase in the delivery / OP performance may be monitored

• Outpatients examined per doctor per day in NA District

• Number of caesarean sections performed in 24 the district hospital out of total number of deliveries conducted

• Number of caesareans performed per 5 obstetrician in the district hospital

• Bed occupancy rate for block PHC

• Bed occupancy rate of district hospital 87.1%

• Percentage of mobile medical camp NA NA NA conducted against number planned

• Average number of OP cases seen per day by NA NA NA the mobile team

• Percentage of blood smears for Malaria 4.6% NA NA Parasite taken out of total Out Patient ( 10% of new OPD)

• Percentage of sputum smears collected for 5% NA NA AFB out of total Out Patient ( 2% of adult OPD)

• Number of PHC/SHC constructions NA NA NA completed against planned

• Number of maternal complications treated 10 NA NA against total number of deliveries

• Percentage of drugs available for Block NA NA NA

PHC per day against the expected number of drugs

• Percentage of JSY payment pending out of 0( March) total deliveries in the District

RCH MONITORING PARAMETERS

Total Population: 1345137 (source 2009-10)

CBR: 26 (SRS 2008 State)

Expected Deliveries per year: 35503(2009-10)

Total reported deliveries: 18086

Institutional deliveries: 11,588

Home non-SBA deliveries: 3845

Home SBA deliveries 2652

Total unreported deliveries: 20,644 probably home- unattended- but also some pvt sector unreported.

LEVEL OF CARE / FACILITIES:

Level 3 Level - 2 Level 1 Total

(CEmONC) (BEmONC) Home & SBA Govt. Pvt. Govt. Pvt. 20/181 HSCs DH-1 No of facilities 7 out of 8 1 4 5 functional as of CHC and 1 0/5 APHCs Referral-1

Level 3 Level - 2 Level 1 Total

(CEmONC) (BEmONC) Home & SBA Govt. Pvt. Govt. Pvt. now (name in referral( out of CHC-8 annexure) 8 CHCs one is not conducting APHC-5 deliveries ) HSCs -181 500 11,588 Institutional deliveries Total Nos of +Home non reported 4810 3 6,278 0 SBA: deliveries in 2009- 3845+Home 10 SBA 2652=18,085 deliveries Normal 4785 6278 500 11563 C- sections 25 4 0 0 Other 505 Complicated Target for 2010- 150 2000 18100 6000 9000 11: total deliveries 0 Total no of 20 HSCs 7 new CHCs facilities construction in 3 APHCs /providers that 1 DH 5 8 existing 8 would be CHCs +5 providing this APHCs level of care 900 at SHCs + 15300 100 Expected normal 4500 8200 450 1100 at home 0 SBA

Level 3 Level - 2 Level 1 Total

(CEmONC) (BEmONC) Home & SBA Govt. Pvt. Govt. Pvt. Expected 0 2700 1500 500 800 150 complicated Target for 2011- NA NA NA NA 12 Total no of NA NA facilities /providers that NA NA NA NA would be providing this level of care Expected normal NA NA NA NA NA NA Expected NA NA NA NA NA complicated

Process Targets NA NA NA NA NA 2 Surgeon 9 On HR – numbers 3Gynaecologi Gynaecologist of doctors, st specialists and 1 anaesthetic 8 SNs exists + nurses 15 SN 4 SNs to add

220 ANMs SBA 20 trained in SBA Trained SNs + 4 Additional to Targeted ANM be trained On training training in SBA 83 2 MOs for EmOC to be Targeted ANM trained training in

Level 3 Level - 2 Level 1 Total

(CEmONC) (BEmONC) Home & SBA Govt. Pvt. Govt. Pvt. IMNCI 50 2 MOs for LSAS to be trained

2 MOs in IMNCI trained , 5 more to be Trained

2 doctors trained in NSV existing 1 proposed 1 PHN

On supervision 1 Certified supervisor On blood 2 blood banks provision On referral transport On Infrastructure 7CHC +5 PHC 300 bed DH + 22HSCs New buildings under under construction construction Renovation On newborn child 1 SNCU 3 NSU care equipment proposed proposed 4

Level 3 Level - 2 Level 1 Total

(CEmONC) (BEmONC) Home & SBA Govt. Pvt. Govt. Pvt. New born corner 3 proposed for 1 DH ISO certification FFHI certified certification

Current level Aim to reach…

Home based Newborn and Sick HBNC ToT is going on Aim to reach 12 days of training child care this year ; subject to gaps supported SNCU – Nil by GOI / other sources

ANM skills in child care IMNCI ToT completed ; 150 ANM in IMNCI training would be taken in 2010-11

Line listing of pregnant women Ongoing To list all pregnancies and children below 2

Facilitation for ASHAs/mothers Nil Proposed in 2010-11 at facility.

NGO involvement 5 NGO Maintain in current level

Family Planning services

Tubectomy FDS – Nil FDS proposed in DH AND 2 CHC

Tubectomy – 7200( Feb 15 cases per week x 50 weeks x 3 2010) centres = 2250

NSV FDS- Nil FDS proposed in DH AND 2 CHC

3 cases per week x 50 weeks 3

NSV 65 (Feb 2010) centres = 450

MTP At FRUs (315) To introduce MVA services

Major Observations with regard to facilities visited (Please attach Facility Monitoring Report as per Annexure2)

______

Major discussion points with ASHA / Beneficiaries /Panchayat members at the village level

a) Water scarcity

b) Drug availability

c) Utilization of Untied funds

d) Institutional delivery at HSC

e) Honorarium of JSY and Immunization

Major discussion points with ANM/LHV/MO at the facility level

a) Human resource problem

b) Utilization of untied fund

c) Bio Medical waste management

d) Common disease pattern in OPD

e) Drug availability

f) Community visit by ANM

g) Facilities in PHC and CHC

Major Observations a) Proper drinking water facility is not available in Jasidih CHC , Sarwan CHC, Sarat CHC and most of the HSC.

b) Lack of Bio medical waste management in the entire visited place.

c) Unhygienic condition of the labour room in Jashidh , Sarwan and Sarat CHC. (In district Hospital labour room is in 1st floor without any lift and Slop).

d) Lack of proper dressing table and material

e) There were no seating arrangements in the OPD area even in District hospital.

F) Unsafe practice in Laboratories

g) Safety issue for new constructed CHC and PHC building

Major actionable points

i. Bio Medical waste management

ii. Hygienic labour room

iii. Proper dressing and examination table

iv. Condemned article free wards

v. Drinking water facility in PHC/ APHC / CHC

vi. District hospital burn Unit management (it was open and full with relatives during visit)

vii. Seating arrangement for patient in OPD area

viii. Proper training/ facilitation to use untied fund (also include MO)

Action taken by consultant on the monitoring feedback

a) Biomedical waste management suggestion b) Suggested some safety measures in laboratory use c) Suggestion to display the drug availability and doctor’s name.

d) Suggestion to use untied fund (MO and VHSC and Sahiyya/ASHA) e) Suggestion for regular community visit (for ANM ) f) Suggestion for labour room (for cleanness and Hygienic practise) ( in district/ Sadar hospital it must be shift on ground floor)

Pradeep Tandan

(Signature and Name of Consultant with Date)

Annexure 2: Facility assessment format

2.1 Sadar Hospital

Inspection format for health facilities

Name of the Consultant : Pradeep Tandan Date & time : 26th April 2010

District: Deoghar Total marks: 125

Name of Facility (APHC/BPHC /Referral/ SD/Sadar): Sadar Hospital

I. Infrastructure

Item MOV Criteria Score Buildin Walls and floor and roof intact 2 g Electrical wires not exposed 1 conditio ! Electric switch boards not broken 2 n Electric bulbs in wards / pathways / toilets 2 11/14 Whitewashed 2

1 Signage boards present 2 Rooms not dumped with condemned articles 0

Conditi a. Mosquito screens present and devoid of holes 0 3/8 on of b. Condemned articles not stored in the wards 1 wards c. window glasses not broken 2 d. Door / Screens / Curtains / present for ensuring 0 privacy of patient

Water a. Running water available for 24 hours in Labour room / 5 supply OT / Toilets 5/10 b. Purified drinking water available for drinking for 0

patients in OP / IP

Conditi a. Doors are not damaged 2 on of b. Floors are clean 2 8/10 toilets c. Basins are not stained 1

d. water taps not damaged, 1 e. pathway is not dirty 2

Patient a. Seating arrangements are present in the OPD area 0 ameniti b. Stools or chairs for attendants in the wards present 0 0/3 es c. Inpatients are provided with blankets in winter 0

Furnitur Cots are not rusted not broken 0 e Mattress not worn out, cloth not torn cotton/coir not 0 0/3 coming out ! Labour board not rusted, not broken, not stained with 0 blood

II. Human Resource (Self improvement score)

Staff performance Baseline data (1st Subsequent visit survey) * (monthly figure ) % improvement Number of deliveries conducted per SBA NA Number of OP cases per doctor NA Bed occupancy rate* NA Number of CS per Obstetrician NA Number of cataract operations per NA ophthalmologist Chest symptomatic sputum population NA examination rate Minor surgeries per doctor NA

Antenatal care severely anaemic (under 7 Not Available gm%) managed rate IUD insertions per trained nurse NA MTP services per trained doctor NA

o Indicative column; subsequent visits (2nd, 3rd etc. Would be scored on improvement and in a fresh inspection form) o Bed occupancy rate=(inpatient days of care/bed days available)×100

III. Services available (applicable for BPHCs and above)

Sl.no Service Means of verification Score 1. 24 hour doctor 1 Duty roster, casuality register available 2. 24 hour nurse available 1 Duty roster, casuality register 3. 24 hour delivery 1 Delivery register 11/16 services available

4. 24 hour newborn care 0 Delivery register, Paediatric ward register, services available Immunization register 5. 24 hour caesarean 1 Delivery register services (if FRU) 6. Tubectomy services 1 FP register available 7. Safe abortion services 1 MTP register available

8. 24 hour blood 1 Blood transfusion register / Blood bank transfusion services master register 9. Laboratory Services 2 Equipments and reagents for conducting the tests are present, lab record shows tests are 1. Haemogram conducted 2. Sputum Examination Lab register 3. Lipid Profile 4. Hormone Assay 5. Urine Examination

10. Availability of ECG 1 ECG machine available & working Facility 11. X Ray Facility available 1 X ray register – working status 12. Ultrasound services 0 USG register – working status available 13. Adolescent sexual and 0 OP register – number of adolescent reproductive health beneficiaries services 14. Functional telephone 0 Telephone number with dial tone 15. Whether fixed day 0 ANC register antenatal clinics are conducted

IV. Services Out-Sourced

Sl. Item Means of verification Score no 1. House Floor is cleaned with disinfectant on the day of visit 1 keeping

rainbow linen colour maintained 1

! OT fumigated 1 8/8

2. Generator Generator in working condition with designated 1 horse power Fuel for operation present 1

3. Food Food served to inpatients 1

Food chart for inpatients 1

4. Ambulance Records of operation [Number of ambulances, average (if more than one ambulance) number of breakdowns in the last one week, number of drivers available per shift] maintained (1 )

V) Equipments and supplies

Item MOV condition Score Trolley In working 1 condition Trolley without 1 2/6 rust

Wheelchair In working 0 condition Wheelchair 0 without rust

Stretcher Stretcher without 0 rust not broken 0

Sterilised gloves Sterilised gloves 1 1/1 available

Average number of Drug stock 6 6/10 OP drugs available register

(monthly) Availability of life Availability of; 4/4 saving drugs Oxytocin 1 present Misoprostol 1

! Magnesium 1 Sulphate IV antibiotics 1

VI. Equipments in Labour room

Equipment MOV Score Spot light in labour room 0 Vacuum extractor 1 ! Resuscitation equipment for newborn – Bag 1 5/7 and mask Resuscitation equipment for newborn –0 Laryngoscope and full set of endo-tracheal tubes Baby resuscitation table with infant warmer 1 1 g. Mucous sucker 1 h. Baby weighing machine 1

VII)Equipment in OT

Equipments MOV score Ceiling OT light/ Floor OT 1 5/6 light (shadowless)

Oxygen cylinder 1 ! Boyles apparatus (only 0 FRU) Suction apparatus 1 Adequate quantity of linen 1 1 Spinal anaesthesia set 1 (FRU)

VIII)Bio-medical Waste Management

Item MOV Score Waste Colour coded buckets 0 3/8 management used Deep burial pit available 0 where anatomical waste is disposed ! Needle cutter in working 1 condition no mix of infectious or 0 non-infectious waste done waste bins not overfilled 1

1 needles and syringes 0 mutilated and disinfected before putting in waste bin metal sharps disposed in 0 puncture proof containers

" disposable gloves and 1` masks not reused

IX) Central sterilization unit

MOV Score Autoclave Functioning autoclave 1 1

Usage of signalac tape 0

! usage of biological 0 indicator swab test of sterile 0 packs

Item MOV score a. Separate column (in delivery register) for recording 0 major complications leading to maternal death 0

b. Delivery register mentions about the details of the baby 2 4/6 and condition of the mother 1 c. Referral slips are issued to patients 1 2

X) Records and reports

XI) Janani Suraksha Yojana

Balance amount Number of mothers yet to Score available receive the JSY money

Appendix 1

Inspection scoring sheet for health facilities

Name of the inspecting officer: Pradeep Tandan Date & time: 26th April 2010

District: Deoghar Total marks: 125

Name of Facility (APHC/BPHC /Referral/ SD/Sadar): Sadar

Item Maximum Facility marks Score I. Infrastructure 48 27

II. Human Resource Self improvement score

III. Services available (applicable for BPHCs 16 11 and above)

IV. Services Out-Sourced 8 8

V) Equipments and supplies 18 13 VI)Equipments in Labour room 7 5 VII)Equipments in OT 6 5 VIII) Bio-medical Waste Management 8 3 IX) Central sterilization unit 2 1 X) Records and reports 6 4 XI) Janani Suraksha Yojana 5 5 Total Score 125 82

2.2 Sarwan Hospital

Inspection format for health facilities

Name of the Consultant : Pradeep Tandan Date & time : 26 th April 2010

District: Deoghar Total marks: 125

Name of Facility (APHC/BPHC /Referral/ SD/Sadar): BPHC Sarwan

II. Infrastructure

Item MOV Criteria Score Building " Walls and floor and roof intact 2 condition Electrical wires not exposed 1 2 Electric switch boards not broken 1

3 Electric bulbs in wards / pathways / toilets 1 5/14 % Whitewashed 2 & Signage boards present 0 Rooms not dumped with condemned articles 0

Conditio e. Mosquito screens present and devoid of holes 0 2/8 n of f. Condemned articles not stored in the wards 1 wards g. window glasses not broken 1 h. Door / Screens / Curtains / present for ensuring 0 privacy of patient

Water c. Running water available for 24 hours in Labour room / 5 supply OT / Toilets 5/10 d. Purified drinking water available for drinking for 0 patients in OP / IP

Conditio f. Doors are not damaged 1 n of g. Floors are clean 0 4/10 toilets h. Basins are not stained 1

i. water taps not damaged, 1 j. pathway is not dirty 1

Patient d. Seating arrangements are present in the OPD area 1 amenities e. Stools or chairs for attendants in the wards present 0 0/3 f. Inpatients are provided with blankets in winter 0

Furniture Cots are not rusted not broken 0 Mattress not worn out, cloth not torn cotton/coir not 0 0/3 coming out 1 Labour board not rusted, not broken, not stained with 0 blood

( New building is in construction phase)

III. Human Resource (Self improvement score)

examination rate Minor surgeries per doctor NA Antenatal care severely anaemic (under 7 gm%) Not Available managed rate IUD insertions per trained nurse NA MTP services per trained doctor NA

nd rd o Indicative column; subsequent visits (2 , 3 etc. Would be scored on improvement and in a fresh inspection form) o Bed occupancy rate=(inpatient days of care/bed days available)×100

IV. Services available (applicable for BPHCs and above)

Sl.no Service Means of verification Score 1. 24 hour doctor available 1 Duty roster, casuality register 2. 24 hour nurse available 1 Duty roster, casuality register 3. 24 hour delivery services 1 Delivery register available 8/16 4. 24 hour newborn care 1 Delivery register, Paediatric ward register,

services available Immunization register 5. 24 hour caesarean 0 Delivery register

services (if FRU) 6. Tubectomy services 1 FP register available 7. Safe abortion services 0 MTP register available 8. 24 hour blood transfusion 0 Blood transfusion register / Blood bank master services register 9. Laboratory Services 1 Equipments and reagents for conducting the tests are present, lab record shows tests are 6. Haemogram conducted 7. Sputum Examination Lab register 8. Lipid Profile 9. Hormone Assay 10. Urine Examination

10. Availability of ECG 1 ECG machine available & working Facility 11. X Ray Facility available 0 X ray register – working status 12. Ultrasound services 0 USG register – working status available 13. Adolescent sexual and 0 OP register – number of adolescent reproductive health beneficiaries services 14. Functional telephone 1 Telephone number with dial tone 15. Whether fixed day 0 ANC register antenatal clinics are conducted

V. Services Out-Sourced

Sl. Item Means of verification Score no 1. House Floor is cleaned with disinfectant on the day of visit 1 keeping rainbow linen colour maintained 0

1 OT fumigated 1 5/8

2. Generator ! Generator in working condition with designated horse 1 power Fuel for operation present 1

3. Food ! Food served to inpatients 0

Food chart for inpatients 0

4. Ambulance Records of operation [Number of ambulances, average (if more than one ambulance) number of breakdowns in the last one week, number of drivers available per shift] maintained (1 )

V) Equipments and supplies

Item MOV condition Score Trolley ! In working 1/2 condition Trolley without 1/2 2/3 rust

Wheelchair ! In working 0 condition Wheelchair 0 without rust

Stretcher ! Stretcher without 1/2 rust not broken 1/2

Sterilised gloves Sterilised gloves 1 1/1 available

Average number of Drug stock register 7 7/10 OP drugs available

(monthly) Availability of life Availability of; 4/4 saving drugs present Oxytocin 1

1 Misoprostol 1

Magnesium 1 Sulphate " IV antibiotics 1

VII. Equipments in Labour room

Equipment MOV Score " Spot light in labour room 0 Vacuum extractor 1 2 Resuscitation equipment for newborn – Bag 1 4/7 and mask 3 Resuscitation equipment for newborn –0 Laryngoscope and full set of endo-tracheal tubes % Baby resuscitation table with infant warmer 0 & g. Mucous sucker 1 h. Baby weighing machine 1

VII)Equipment in OT

Equipments MOV score Ceiling OT light/ Floor OT 0 3/6 light (shadowless)

" Oxygen cylinder 1 Boyles apparatus (only FRU) 0 2 Suction apparatus 1 3 Adequate quantity of linen 1 % Spinal anaesthesia set (FRU) 0

VIII)Bio-medical Waste Management

Item MOV Score Waste management Colour coded buckets 0 4/8 used 2 Deep burial pit available 0 where anatomical waste is disposed 3 Needle cutter in working 1 condition

% no mix of infectious or 0 non-infectious waste done & waste bins not overfilled 0

needles and syringes 1 mutilated and disinfected before putting in waste bin ( metal sharps disposed in 0 puncture proof containers $ disposable gloves and 1` masks not reused

IX) Central sterilization unit

MOV Score Autoclave Functioning autoclave 1 1

1 Usage of signalac tape 0

usage of biological 0 indicator " swab test of sterile 0 packs

Item MOV score d. Separate column (in delivery register) for recording 0

major complications leading to maternal death 0 e. Delivery register mentions about the details of the baby 2 4/6 and condition of the mother 1 f. Referral slips are issued to patients 1 2

X) Records and reports

XI) Janani Suraksha Yojana

Balance amount Number of mothers yet to Score available receive the JSY money

Appendix 2

Inspection scoring sheet for health facilities

Name of the inspecting officer: Pradeep Tandan Date & time: 26th April 2010

District: Deoghar Total marks: 125

Name of Facility (APHC/BPHC /Referral/ SD/Sadar): BPHC Sarwan

Item Maximum Facility marks Score

II. Infrastructure 48 16

III. Human Resource Self improvement score

IV. Services available (applicable for BPHCs 16 8 and above)

V. Services Out-Sourced 8 5

V) Equipments and supplies 18 14 VI)Equipments in Labour room 7 4 VII)Equipments in OT 6 3 VIII) Bio-medical Waste Management 8 4 IX) Central sterilization unit 2 1 X) Records and reports 6 4 XI) Janani Suraksha Yojana 5 5 Total Score 125 64

2.3 Sarath Hospital

Inspection format for health facilities

Name of the Consultant : Pradeep Tandan Date & time : 26 th April 2010

District: Deoghar Total marks: 125

Name of Facility (APHC/BPHC /Referral/ SD/Sadar): BPHC Sarath

III. Infrastructure

Item MOV Criteria Score Building ( Walls and floor and roof intact 2 condition $ Electrical wires not exposed 0 4 Electric switch boards not broken 0

Electric bulbs in wards / pathways / toilets 1 5/14 Whitewashed 2 Signage boards present 0 Rooms not dumped with condemned articles 0

Conditio i. Mosquito screens present and devoid of holes 0 2/8 n of j. Condemned articles not stored in the wards 1 wards k. window glasses not broken 1 l. Door / Screens / Curtains / present for ensuring 0 privacy of patient

Water e. Running water available for 24 hours in Labour room / 5 supply OT / Toilets 5/10 f. Purified drinking water available for drinking for 0 patients in OP / IP

Conditio k. Doors are not damaged 1 n of l. Floors are clean 0 4/10 toilets m. Basins are not stained 1

n. water taps not damaged, 1 o. pathway is not dirty 1

Patient g. Seating arrangements are present in the OPD area 0 amenities h. Stools or chairs for attendants in the wards present 0 0/3 i. Inpatients are provided with blankets in winter 0

Furniture Cots are not rusted not broken 0 " Mattress not worn out, cloth not torn cotton/coir not 0 0/3 coming out Labour board not rusted, not broken, not stained with 0 blood

( New building is in construction phase)

IV. Human Resource (Self improvement score)

o Indicative column; subsequent visits (2nd, 3rd etc. Would be scored on improvement and in a fresh inspection form) o Bed occupancy rate=(inpatient days of care/bed days available)×100

V. Services available (applicable for BPHCs and above)

Sl.no Service Means of verification Score 1. 24 hour doctor available 1 Duty roster, casuality register 2. 24 hour nurse available 1 Duty roster, casuality register 3. 24 hour delivery services 1 Delivery register available 7/16 4. 24 hour newborn care 1 Delivery register, Paediatric ward register,

services available Immunization register 5. 24 hour caesarean 0 Delivery register services (if FRU) 6. Tubectomy services 1 FP register available 7. Safe abortion services 0 MTP register available 8. 24 hour blood transfusion 0 Blood transfusion register / Blood bank master services register 9. Laboratory Services 1 Equipments and reagents for conducting the tests are present, lab record shows tests are 11. Haemogram conducted 12. Sputum Examination Lab register 13. Lipid Profile 14. Hormone Assay 15. Urine Examination

10. Availability of ECG 1 ECG machine available & working Facility

11. X Ray Facility available 0 X ray register – working status 12. Ultrasound services 0 USG register – working status available 13. Adolescent sexual and 0 OP register – number of adolescent reproductive health beneficiaries services 14. Functional telephone 0 Telephone number with dial tone 15. Whether fixed day 0 ANC register antenatal clinics are conducted

VI. Services Out-Sourced

Sl. Item Means of verification Score no 1. House Floor is cleaned with disinfectant on the day of visit 1 keeping " rainbow linen colour maintained 0

OT fumigated 0 4/8

2. Generator Generator in working condition with designated horse 1 power 1 Fuel for operation present 1

3. Food Food served to inpatients 0

1 Food chart for inpatients 0

4. Ambulance Records of operation [Number of ambulances, average (if more than one ambulance) number of breakdowns in the last one week, number of

drivers available per shift] maintained (1 )

V) Equipments and supplies

Item MOV condition Score Trolley In working 1/2 condition 1 Trolley without 1/2 2/3 rust

Wheelchair In working 0 condition 1 Wheelchair 0 without rust

Stretcher Stretcher without 1/2 rust 1 not broken 1/2

Sterilised gloves ! Sterilised gloves 1 1/1 available

Average number of ! Drug stock register 5 5/10 OP drugs available

(monthly) Availability of life Availability of; 4/4 saving drugs present Oxytocin 1

2 Misoprostol 1

3 Magnesium 1 Sulphate

% IV antibiotics 1

VIII. Equipments in Labour room

Equipment MOV Score ( Spot light in labour room 0 $ Vacuum extractor 1 4 Resuscitation equipment for newborn – Bag 1 4/7 and mask Resuscitation equipment for newborn –0 Laryngoscope and full set of endo-tracheal tubes Baby resuscitation table with infant warmer 0 g. Mucous sucker 1 h. Baby weighing machine 1

VII)Equipment in OT

Equipments MOV score & Ceiling OT light/ Floor OT 0 3/6 light (shadowless)

Oxygen cylinder 1 ( Boyles apparatus (only FRU) 0 $ Suction apparatus 1 4 Adequate quantity of linen 1 Spinal anaesthesia set (FRU) 0

VIII)Bio-medical Waste Management

Item MOV Score Waste management 4 Colour coded buckets 0 2/8 used Deep burial pit available 0 where anatomical waste is disposed Needle cutter in working 1 condition no mix of infectious or 0 non-infectious waste done waste bins not overfilled 0

* needles and syringes 0 mutilated and disinfected before putting in waste bin . metal sharps disposed in 0 puncture proof containers disposable gloves and 1` masks not reused

IX) Central sterilization unit

MOV Score Autoclave Functioning autoclave 1 1

2 Usage of signalac tape 0

3 usage of biological 0 indicator % swab test of sterile 0 packs

X) Records and reports

Item MOV score g. Separate column (in delivery register) for recording 0 major complications leading to maternal death 0 h. Delivery register mentions about the details of the baby 2 4/6 and condition of the mother 1 i. Referral slips are issued to patients 1 2

XI) Janani Suraksha Yojana

Balance amount Number of mothers yet to Score available receive the JSY money

Appendix 3

Inspection scoring sheet for health facilities

Name of the inspecting officer: Pradeep Tandan Date & time: 26th April 2010

District: Deoghar Total marks: 125

Name of Facility (APHC/BPHC /Referral/ SD/Sadar): BPHC Sarat

Item Maximum Facility marks Score III. Infrastructure 48 16

IV. Human Resource Self improvement score

V. Services available (applicable for BPHCs 16 7 and above)

VI. Services Out-Sourced 8 4

V) Equipments and supplies 18 12 VI)Equipments in Labour room 7 4 VII)Equipments in OT 6 3 VIII) Bio-medical Waste Management 8 2 IX) Central sterilization unit 2 1 X) Records and reports 6 4 XI) Janani Suraksha Yojana 5 5 Total Score 125 58

2.4 Palajori Hospital

Inspection format for health facilities

Name of the Consultant : Pradeep Tandan Date & time : 26 th April 2010

District: Deoghar Total marks: 125

Name of Facility (APHC/BPHC /Referral/ SD/Sadar): BPHC Palajori

IV. Infrastructure

Item MOV Criteria Score Building * Walls and floor and roof intact 2 condition . Electrical wires not exposed 2 Electric switch boards not broken 1

Electric bulbs in wards / pathways / toilets 1 8/14 5 Whitewashed 2 Signage boards present 0 Rooms not dumped with condemned articles 0

Conditio m. Mosquito screens present and devoid of holes 0 4/8 n of n. Condemned articles not stored in the wards 1 wards o. window glasses not broken 1 p. Door / Screens / Curtains / present for ensuring 2 privacy of patient

Water g. Running water available for 24 hours in Labour room / 5 supply OT / Toilets 5/10 h. Purified drinking water available for drinking for 0 patients in OP / IP

Conditio p. Doors are not damaged 1 n of q. Floors are clean 1 5/10 toilets r. Basins are not stained 1

s. water taps not damaged, 1 t. pathway is not dirty 1

Patient j. Seating arrangements are present in the OPD area 0 amenities k. Stools or chairs for attendants in the wards present 0 0/3 l. Inpatients are provided with blankets in winter 0

Furniture 2 Cots are not rusted not broken 0 3 Mattress not worn out, cloth not torn cotton/coir not 0 0/3 coming out % Labour board not rusted, not broken, not stained with 0 blood

( New building is in construction phase)

V. Human Resource (Self improvement score)

o Indicative column; subsequent visits (2nd, 3rd etc. Would be scored on improvement and in a fresh inspection form) o Bed occupancy rate=(inpatient days of care/bed days available)×100

VI. Services available (applicable for BPHCs and above)

Sl.no Service Means of verification Score 1. 24 hour doctor available 1 Duty roster, casuality register 2. 24 hour nurse available 1 Duty roster, casuality register 3. 24 hour delivery services 1 Delivery register available 7/16 4. 24 hour newborn care 1 Delivery register, Paediatric ward register,

services available Immunization register 5. 24 hour caesarean 0 Delivery register services (if FRU) 6. Tubectomy services 1 FP register available 7. Safe abortion services 0 MTP register available 8. 24 hour blood transfusion 0 Blood transfusion register / Blood bank master services register 9. Laboratory Services 1 Equipments and reagents for conducting the tests are present, lab record shows tests are 16. Haemogram conducted 17. Sputum Examination Lab register 18. Lipid Profile 19. Hormone Assay 20. Urine Examination

10. Availability of ECG 1 ECG machine available & working Facility

VII. Services Out-Sourced

Sl. Item Means of verification Score no 1. House 2 Floor is cleaned with disinfectant on the day of visit 1 keeping 3 rainbow linen colour maintained 0

% OT fumigated 0 4/8

2. Generator Generator in working condition with designated horse 1 power " Fuel for operation present 1

3. Food Food served to inpatients 0

" Food chart for inpatients 0

4. Ambulance Records of operation [Number of ambulances, average (if more than one

ambulance) number of breakdowns in the last one week, number of drivers available per shift] maintained (1 )

V) Equipments and supplies

Item MOV condition Score Trolley In working 1/2 condition " Trolley without 1/2 2/3 rust

Wheelchair In working 0 condition " Wheelchair 0 without rust

Stretcher Stretcher without 1/2 rust " not broken 1/2

Sterilised gloves Sterilised gloves 1 1/1 available

Average number of Drug stock register 8 8/10 OP drugs available

(monthly) Availability of life Availability of; 4/4 saving drugs present & Oxytocin 1

Misoprostol 1

( Magnesium 1 Sulphate

$ IV antibiotics 1

IX. Equipments in Labour room

Equipment MOV Score * Spot light in labour room 0 . Vacuum extractor 1 Resuscitation equipment for newborn – Bag 1 4/7 and mask Resuscitation equipment for newborn –0 Laryngoscope and full set of endo-tracheal tubes 5 Baby resuscitation table with infant warmer 0 g. Mucous sucker 1 h. Baby weighing machine 1

VII)Equipment in OT

Equipments MOV score Ceiling OT light/ Floor OT 1 4/6 light (shadowless)

Oxygen cylinder 1 Boyles apparatus (only FRU) 0 * Suction apparatus 1 . Adequate quantity of linen 1 Spinal anaesthesia set (FRU) 0

VIII)Bio-medical Waste Management

Item MOV Score Waste management Colour coded buckets 0 4/8 used 5 Deep burial pit available 1 where anatomical waste is disposed Needle cutter in working 1 condition no mix of infectious or 0 non-infectious waste done !! waste bins not overfilled 1

needles and syringes 0 mutilated and disinfected before putting in waste bin metal sharps disposed in 0 puncture proof containers 11 disposable gloves and 1` masks not reused

IX) Central sterilization unit

MOV Score Autoclave & Functioning autoclave 1 1

Usage of signalac tape 0

( usage of biological 0 indicator $ swab test of sterile 0 packs

X) Records and reports

Item MOV score j. Separate column (in delivery register) for recording 0 major complications leading to maternal death 0 k. Delivery register mentions about the details of the baby 2 4/6 and condition of the mother 1 l. Referral slips are issued to patients 1 2

XI) Janani Suraksha Yojana

Balance amount Number of mothers yet to Score available receive the JSY money

Appendix 4

Inspection scoring sheet for health facilities

Name of the inspecting officer: Pradeep Tandan Date & time: 26th April 2010

District: Deoghar Total marks: 125

Name of Facility (APHC/BPHC /Referral/ SD/Sadar): BPHC Palajori

Item Maximum Facility marks Score IV. Infrastructure 48 22

V. Human Resource Self improvement score

VI. Services available (applicable for BPHCs 16 7 and above)

VII. Services Out-Sourced 8 4

V) Equipments and supplies 18 15 VI)Equipments in Labour room 7 4 VII)Equipments in OT 6 4 VIII) Bio-medical Waste Management 8 4 IX) Central sterilization unit 2 1 X) Records and reports 6 4 XI) Janani Suraksha Yojana 5 5 Total Score 125 69

2.5 Jasidih Hospital

Inspection format for health facilities

Name of the Consultant : Pradeep Tandan Date & time : 26 th April 2010

District: Deoghar Total marks: 125

Name of Facility (APHC/BPHC /Referral/ SD/Sadar): BPHC Jasidih

V. Infrastructure

Item MOV Criteria Score Building !! Walls and floor and roof intact 1 condition Electrical wires not exposed 1 Electric switch boards not broken 1

11 Electric bulbs in wards / pathways / toilets 0 5/14 Whitewashed 2 "" Signage boards present 0 Rooms not dumped with condemned articles 0

Conditio q. Mosquito screens present and devoid of holes 0 2/8 n of r. Condemned articles not stored in the wards 1 wards s. window glasses not broken 1 t. Door / Screens / Curtains / present for ensuring 0 privacy of patient

Water i. Running water available for 24 hours in Labour room / 0 supply OT / Toilets 0/10 j. Purified drinking water available for drinking for 0 patients in OP / IP

Conditio u. Doors are not damaged 1 n of v. Floors are clean 0 3/10 toilets w. Basins are not stained 1

x. water taps not damaged, 1 y. pathway is not dirty 0

Patient m. Seating arrangements are present in the OPD area 0 amenities n. Stools or chairs for attendants in the wards present 0 0/3 o. Inpatients are provided with blankets in winter 0

Furniture & Cots are not rusted not broken 0 Mattress not worn out, cloth not torn cotton/coir not 0 0/3 coming out ( Labour board not rusted, not broken, not stained with 0 blood

( New building is in construction phase)

VI. Human Resource (Self improvement score)

o Indicative column; subsequent visits (2nd, 3rd etc. Would be scored on improvement and in a fresh inspection form) o Bed occupancy rate=(inpatient days of care/bed days available)×100

VII. Services available (applicable for BPHCs and above)

Sl.no Service Means of verification Score 1. 24 hour doctor available 1 Duty roster, casuality register 2. 24 hour nurse available 1 Duty roster, casuality register 3. 24 hour delivery services 1 Delivery register available 6/16 4. 24 hour newborn care 0 Delivery register, Paediatric ward register,

Examination Lab register 23. Lipid Profile 24. Hormone Assay 25. Urine Examination

10. Availability of ECG 1 ECG machine available & working Facility 11. X Ray Facility available 0 X ray register – working status 12. Ultrasound services 0 USG register – working status available 13. Adolescent sexual and 0 OP register – number of adolescent reproductive health beneficiaries services 14. Functional telephone 0 Telephone number with dial tone 15. Whether fixed day 0 ANC register antenatal clinics are conducted

VIII. Services Out-Sourced

Sl. Item Means of verification Score no 1. House & Floor is cleaned with disinfectant on the day of visit 0 keeping rainbow linen colour maintained 0

( OT fumigated 0 2/8

2. Generator Generator in working condition with designated horse 1 power

2 Fuel for operation present 1

3. Food Food served to inpatients 0

2 Food chart for inpatients 0

4. Ambulance Records of operation [Number of ambulances, average (if more than one ambulance) number of breakdowns in the last one week, number of drivers available per shift] maintained (1 )

V) Equipments and supplies

Item MOV condition Score Trolley In working 1/2 condition 2 Trolley without 1/2 1/3 rust

Wheelchair In working 0 condition 2 Wheelchair 0 without rust

Stretcher Stretcher without rust 2 not broken

Sterilised gloves Sterilised gloves 1 1/1 available

Average number of Drug stock register 6 6/10 OP drugs available

(monthly)

Availability of life Availability of; 4/4 saving drugs present 4 Oxytocin 1

Misoprostol 1

Magnesium 1 Sulphate IV antibiotics 1

X. Equipments in Labour room

Equipment MOV Score !! Spot light in labour room 0 Vacuum extractor 0 Resuscitation equipment for newborn – Bag 1 4/7 and mask 11 Resuscitation equipment for newborn –0 Laryngoscope and full set of endo-tracheal tubes Baby resuscitation table with infant warmer 0 "" g. Mucous sucker 1 h. Baby weighing machine 1

VII)Equipment in OT

Equipments MOV score Ceiling OT light/ Floor OT 0 3/6 light (shadowless)

5 Oxygen cylinder 1

Boyles apparatus (only FRU) 0 Suction apparatus 1 !! Adequate quantity of linen 1 Spinal anaesthesia set (FRU) 0

VIII)Bio-medical Waste Management

Item MOV Score Waste management Colour coded buckets 0 2/8 used "" Deep burial pit available 0 where anatomical waste is disposed Needle cutter in working 1 condition 22 no mix of infectious or 0 non-infectious waste done 33 waste bins not overfilled 0

%% needles and syringes 0 mutilated and disinfected before putting in waste bin

& & metal sharps disposed in 0 puncture proof containers disposable gloves and 1` masks not reused

IX) Central sterilization unit

MOV Score Autoclave 4 Functioning autoclave 1 1

Usage of signalac tape 0

usage of biological 0 indicator swab test of sterile 0 packs

X) Records and reports

Item MOV score m. Separate column (in delivery register) for recording 0 major complications leading to maternal death 0 n. Delivery register mentions about the details of the baby 2 4/6 and condition of the mother 1 o. Referral slips are issued to patients 1 2

XI) Janani Suraksha Yojana

Balance amount Number of mothers yet to Score available receive the JSY money

Appendix 5

Inspection scoring sheet for health facilities

Name of the inspecting officer: Pradeep Tandan Date & time: 26th April 2010

District: Deoghar Total marks: 125

Name of Facility (APHC/BPHC /Referral/ SD/Sadar): BPHC Jasidih

Item Maximum Facility marks Score V. Infrastructure 48 10

VI. Human Resource Self improvement score

VII. Services available (applicable for BPHCs 16 6 and above)

VIII. Services Out-Sourced 8 2

V) Equipments and supplies 18 10 VI)Equipments in Labour room 7 4 VII)Equipments in OT 6 3 VIII) Bio-medical Waste Management 8 2

IX) Central sterilization unit 2 1 X) Records and reports 6 4 XI) Janani Suraksha Yojana 5 5 Total Score 125 47

Annexure 3: District Profile

Census year Sl. No. Parameter 1991 2001 T R U T R U 1 Population : Persons 933113 807954 125159 1165390 1005539 159851 Males 488229 419914 68315 608878 522198 86680 Females 444884 388040 56844 556512 483341 73171 2 Decadal growth rate : 31.64 24.89 3 Density : 376 470 4 Sex ratio (TotalPopulation) : 911 924 832 914 926 844 5 Sex ratio ( 0 - 6 Population) : 987 997 902 973 980 910 6 Percentage of 0-6 Population : Persons 21.63 22.35 17.00 19.54 20.42 14.00 Males 20.81 21.53 16.38 18.96 19.87 13.52 Females 22.54 23.24 17.75 20.18 21.03 14.57 7 Percentage of Urban Population : 13.41 13.72 8 Literacy rate : Persons 37.92 32.11 73.00 50.09 44.55 82.33 Males 54.12 49.19 82.52 66.38 62.22 89.62 Females 19.74 13.20 61.37 31.99 25.18 73.59 9 Percentage of Main Workers : Persons 29.46 30.29 24.06 24.34 24.55 23.08 Males 48.60 49.73 41.65 39.49 39.54 39.20 Females 8.45 9.27 2.92 7.78 8.35 3.98 10 Percentage of Marginal Persons 5.42 6.20 0.41 12.79 14.45 2.32 Workers : Males 0.73 0.81 0.27 9.82 10.96 2.98 Females 10.56 12.03 0.58 16.03 18.22 1.54 11 Percentage of Non Workers : Persons 65.12 63.51 75.53 62.87 61.00 74.60 Males 50.67 49.46 58.08 50.69 49.51 57.82 Females 80.98 78.71 96.50 76.20 73.43 94.48 12 Percentage of SC Population : Persons 12.40 13.02 8.41 12.60 13.30 8.20

Males 12.34 13.02 8.16 12.53 13.28 8.06 Females 12.46 13.01 8.72 12.68 13.33 8.37 13 Percentage of ST Population : Persons 12.76 14.40 2.17 12.25 13.87 2.05 Males 12.48 14.14 2.29 11.95 13.59 2.10 Females 13.07 14.69 2.03 12.57 14.17 1.99

1991 Census 2001 Census Area in Sq. Km 2479

No. of Subdivisions 2

No. of C.D.Blocks 7 8 No. of Villages

(a) Total 2704 2706 (b) Inhabited 2327 2356 (c) Uninhabited 377 350 No. of UA's 1 1 No. of Statutory Towns 3 3 Most populous village in the district Rohini 5991

Least populous village in the district Durgapur 1

Most populous C.D.Block Deoghar 256063

Least populous C.D.Block Devipur 84658

C.D Block having highest literacy rate

Total Deoghar 66.50

Female Deoghar 51.52

C.D Block having lowest literacy rate Total Devipur 39.75

Female Devipur 20.11

Town having highest literacy rate Total Deoghar (M) 86.63

Female Deoghar (M) 79.28

Town having lowest literacy rate Total Madhupur (M) 74.93

Female Jasidih (NA) 64.23

Annexure 4 : Human resources in Deoghar District.

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